BASIS STATEMENT

90-590 Maine Health Data Organization

Chapter 270: Uniform Reporting System for Quality Data Sets

MAJOR SUBSTANTIVE RULE

The Maine Health Data Organization is authorized by statute to collect quality data from hospitals and ambulatory surgery facilities to support the set of quality measures adopted by the Maine Quality Forum with the goal to improving the quality of healthcare in Maine.

This major substantive rule was provisionally adopted by the Maine Health Data Organization on January 7, 2016. As a major substantive rule, it was sent to the Legislature for approval. On March 29, 2016, the Legislature authorized adoption of the amended rule, as an emergency. Resolves 2015, ch. 71.

The following represent the changes to the rule and the rationale for these changes:

1.  Deleted the following definitions: Antibiotic Timing; Beta Blocker; High Risk for Methicillin-resistant Staphylococcus Aureus; Initial Antibiotic selection; Licensed Vocational Nurse/Licensed Practical Nurse; Normothermia; Nosocomial; Prophylactic Antibiotic; Registered Nurse; Serum Glucose; Unlicensed Assistive Personnel; Vest or limb Restraint; Venous Thromboembolism Prophylaxis; and Voluntary Uncontrolled Separation.

One of the goals of this proposed rule change is to update the definitions section of the rule by deleting those definitions that are no longer used in the rule. This section has not kept up with the previous revisions to the rule.

2.  Deleted Section 2 (Hospital Health Care Quality Data Set Filing Description).

MHDO deleted this section from Chapter 270 because the measures in Section 2 have “topped out” meaning there is little room for improvement. We have been collecting this data for over 10 years and have seen great improvement over time. The Centers for Medicare and Medicaid (CMS) has also collected these measures nationally for many years and they made the decision to suspend the collection of these measures.

3.  Section 2(A) – MHDO deleted duplicative language identifying HAI-1 and HAI-2.

MHDO added language to HAI-1 to conform to the expanded list of hospital units eligible for reporting data for the HAI-1 measure as defined by the measure steward, NHSN. MHDO also deleted duplicative language in this section in an effort to simplify the language.

4.  Section 2(C) – The following revisions were made to Section 2(C):

·  Change reporting of MRSA infection rates to MRSA Lab ID Events-this revision updates Chapter 270 language to current practice.

·  Change MRSA reporting from facility-wide and by unit location to facility-wide only-this revision was made because neither the Maine Quality Forum (MQF) nor the Maine CDC make use of the hospital unit-level data. The MQF HAI Annual Report (submitted to the Legislature) presents facility-wide data only.

·  Change "on a monthly basis" to "in accordance with NHSN specifications"-this revision was made to conform to the requirements of the measure steward, NHSN.

5.  Section 2(D) – The language the MHDO deleted in Section 2(D) aligns with the measure steward regarding periodicity and we moved the reference to Maine CDC and MHDO's access to NHSN MRSA data to new sections 3F and 3G. This change avoids repeating the same language for MRSA and again for C.diff.

6.  Section 2(F)-MHDO deleted the word future to eliminate any confusion regarding the MQF and Maine CDC’s access to healthcare associated infection measures mandated by the CMS.

7.  Section 2(F) and (G) – MHDO created a 2(F) and (G). The language in 2(F) and (G) are not a new requirement but rather clarifies and replaces the repetitive language that was deleted from Sections 3C (MRSA) and 3D (C.diff.)

8.  Section 3: (Nursing –Sensitive Patient-Centered Health Care Quality Data Filing Description)

The board deleted the NSPC 4 measure based on the fact that no entity has requested this data and it is not publically reported. The technical references to NSPC-4 are being removed since that measure will no longer be collected.

9.  Deleted Section 5 (Nursing Sensitive System Centered Health Care Quality Data Set Filing Description).

The basis for this decision is that the data in Section 5 has been collected by the MHDO for over ten years with only a few entities requesting the data recently. None of the commenters in opposition of the elimination of these measures has ever requested this data. The MHDO board believes that there are better indicators of quality that measure nursing care. For example, the measures in Section 3 of the Rule Nursing-Sensitive Patient-Centered Health Care Quality Data Set. The Board believes the measures in Section 3 are the measures that we should consider publically reporting via the CompareMaine website.

10. Deleted Section 6 (3 Item Care Transition Measure (CTM) Health Care Quality Data Set Filing Description

In order to reduce redundancy, the board deleted these measures as this data is available through CMS.

11. Section 7(C) (Submission Requirements-Filing Periods). MHDO changed the filing dates.

The change in Section 7(C) is to align the States filing deadlines with the CMS filing deadlines.

Pursuant to 5 M.R.S. Sec. 8056(10)(Minor errors), MHDO is making the following changes to the rule in order to correct minor, clerical errors:

a.  Section 3 (Nursing-Sensitive Patient-Centered Health Care Quality Data Set Filing Description): Deleted the references to “NSPC 4” because NSPC 4 had been deleted in the proposed rule.

b.  Section 4(C) (Submission Requirements- Filing Periods): last paragraph, substituted “Section 2” for “Section 3.” The reason for this is because this reflects the numbering change which had been made in the proposed rule.

c.  Section 5 (A)(2)(Standards for Data; Notification; Response – Standards): (1) the proposed rule removed the SCIP measures, so all references to SCIP have been deleted; (2) References to Section 4 and 5 metrics have been deleted since those metrics were deleted in the proposed rule; (3) References to NSSC have been deleted since NSSC was deleted in the proposed rule; (4) References to CTM (Care Transition Measures) have been deleted since CTM (Section 5) was eliminated in the proposed rule.

d.  Section 5(C) (Resubmission): “Subsection 9” was replaced with “Subsection 5 B” since the proposed rule deleted subsection 9.

Statutory Authority: 22 M.R.S.A., §8704, sub-§4, §8708-A, and 24-A M.R.S.A., §§6951 (2) & (3); Resolves 2015, ch. 71.

Effective Date: This rule will become effective 30 days after it is filed with the Secretary of State.

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